Name:

Date of Birth:

Drivers License Number:

Address:

City:

Province / State:

Country:

Postal / Zip Code:

Telephone: Please Include Area Code

Fax: Please Include Area Code

Email Address:

Occupation:

Years of Boating Experience:

Years as Boat Owner:

Boating Courses Completed:

Yacht Club Member: Select Yes No

Yacht Club Name:

Previous Vessels Owned:

Manufacturer: Year:

Model:

Purchase Date: Purchase Price:

Current Market Value:

Vessel Name:

Length: Type: Select Runabout Catamaran Cruiser Houseboat Sailboat Aux.Sailboat Ski-Boat Max Speed: Select km/h mi/h

Hull Construction: Select Fiberglass Wood Aluminum Steel Other Other:

Registration Number:

Engine Manufacturer:

Number Of Engines:

Engine HP (each): Year:

Engine Type: Select Outboard Inboard Sterndrive, I/O Jet Fuel: Select Diesel Gas

Primary Moorage Location: (name, city, province/state)

Date Last Surveyed: Market Value:

Tender Manufacturer:

Year: Length: Value:

Tender Outboard:

Year: HP: Value:

Trailer Make:

Year: Value:

Present Carrier: Annual Premium:

Policy Effective Date: Policy Expiration Date:

Personal Effects:

P & I Liability:

Is Boat: Select Pleasure Charter Live Aboard

Navigation Area: Select West Coast Fresh Water Lakes and Rivers Other

List all hull and / or liability losses you have had regarding this vessel or any other for the past 5 years.

Date: Type of Loss: Amount:

Brief Description:

How did you find us? Select Web Search Engine Boat Dealer Marina Newspaper Referral Boat Show Current Customer Magazine Ad Pacific Yachting Boat Journal Latitude 38

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